RESIDENTIAL HEAT PUMP REBATE APPLICATION

Name:__________________________________________ Co-op Account #_________________________

Address where appliance will be installed:__________________________________________________

City____________________________ State____________ ZIP___________ Phone________________

M ili dd (if diff t th th i t ll ti dd )Mailing address (if different than the installation address):______________________________________

City____________________________ State____________ ZIP___________ Phone________________

Information about your home: Age ____ yrs. Size ______ sq. ft. No. of people living in the home _____

What type of dwelling structure is this heat pump installed at? (check one)Si l f il h H / F M lti it d lli M f t d ( i l /d bl ) Oth

Not at all Very Much1 2 3 4 5

□ Single family house □ House w/ Farm □ Multi-unit dwelling □ Manufactured (single/double) □ Other

Did this rebate influence your decision to buy the appliance?

If installed in an existing home, what type of heating system did the home have previously? (check one)□ Gas Forced Air □ Electric Forced Air □ Electric Baseboard □ Heat Pump □ Other (specify)_________

What type of cooling system will the heat pump replace? (check one)What type of cooling system will the heat pump replace? (check one)□ Central Air Conditioning □ Window Air Conditioners (how many?___) □ Heat Pump □ None

What type of back-up (supplemental) heating system does your new heat pump use? (check one)□ None □ Existing Gas Furnace □ New Gas Furnace □ Existing Electric Furnace □ New Electric Furnace

I certify that the heat pump listed below is a qualifying ENERGY STAR® heat pump that will be installed at the address listed above. I agree to allow a representative of the Cooperative to verify the heat pump i t ll ti t th b dd

HEAT PUMP EQUIPMENT INFORMATION:

Type ______________ Manufacturer _______________________ Model ________________________air or ground source

installation at the above address.

Signature: _________________________________________________Date: _____________________

SEER / EER Rating ____________ Capacity in Tons ________ Installation Date ___________________

RETAILER-CONTRACTOR INFORMATION:

HVAC Contractor Name __________________________ Contact Person _________________________

Address PhoneAddress _______________________________________________________ Phone ________________

I certify that the equipment information is accurate, including claims of efficiency, size and HVAC system information. I recognize that the Cooperative may verify the information that I have provided.

Contractor’s Signature:_______________________________________ Date:______________________All account information will be kept confidential between the Cooperative, Associated Electric Cooperative and agents acting on their behalf.

RESIDENTIAL HEAT PUMP REBATE APPLICATION

ELIGIBLE CUSTOMERS• Cooperative residential members are eligible for rebates when buying qualifying, air source or groundsource (geothermal) heat pumps.• The structure in which the member resides must be a permanent structure on a permanent foundationon land owned by the member.

RESIDENTIAL HEAT PUMP REBATE APPLICATION

ELIGIBLE HEAT PUMP EQUIPMENT• Equipment must be a new, matched heat pump system certified by ENERGY STAR®.• Ground source heat pumps must be installed with a Delta T of 80. A Manual J calculation will be usedto support the Delta T. Please ask your HVAC contractor to verify that these requirements are met.• The Cooperative may inspect the home to determine if appropriate insulation is present in the ceilingand walls.• Heat pumps that receive rebates may be subject to Cooperative load control programs. The participantagrees to allow the Cooperative to control their heating and cooling equipment now or in the future.

EXISTING EQUIPMENT• Space Heating: The heat pump may be used to replace existing electric resistance, natural gas orpropane space heating equipment in the home.• Air Conditioning: The heat pump must replace either a central air conditioning system or a minimum oftwo window air conditioning units.

REBATE DETAILS• The Cooperative issues cash rebates in the form of checks, not energy bill credits.• Please submit one rebate application per heat pump.• A copy of the data sales receipt or invoice must be included with the rebate application.• The application must include all the information requested on the front of this application.• Incomplete applications will not be processed and will be returned to the member.• Please allow at least 6-8 weeks for rebate processing. Please keep a copy for your records.

DISCLAIMERThe Cooperative is not responsible if your HVAC contractor, retailer, builder or other party provides you with inaccurate information about the amount or conditions of the actual rebate. The Cooperative will not rebate equipment that has been mislabeled or misrepresented. The Cooperative reserves the right to inspect the heat pump and its installation at the address indicated on the front of this application. The Cooperative is not responsible for any lost late stolen ineligible illegible misdirected or postage dueCooperative is not responsible for any lost, late, stolen, ineligible, illegible, misdirected or postage due mail. All completed applications will become the property of the Cooperative. Rebate qualifications and amounts are subject to change at the Cooperative’s discretion and the program may end at any time without notice.

SEND COMPLETED APPLICATIONS TO:

For Office Use OnlyDate Received _______________Acct. No. ____________________Approval ____________________

Rebate Date

FOR OFFICE USE ONLY

**ALL INFORMATION MUST BE FILLED OUT IN ORDER TO RECEIVE REBATE**

TOTALRebate Amount $

/ /

Telephone Number

- -Account Number Map Location

Street or PO Box

Substation

City Zip Code

First Name I. Last Name

1. What heating, cooling, or home appliance(s) did you install to qualify for rebate? (all that apply)

Electric water heaterGeothermal (ground source) heat pumpAir source heat pump

Window air conditionerClothes washerDishwasher

For water heater installation, start with Section II; heat pump, SectionIII; other appliances, Section IV.

2. If this was installed as part of your new home construction, who was your builder/contractor?

I. Your Rebate

I will allow Lake Region Electric to install a load management device.

X

II. Water Heater Installation

/ /

8. This water heater is replacing:

6. Water heater manufacturer:

None, new construction/installationPropane water heaterElectric water heater

Natural gas water heaterOther

If you didn't also install a heat pump, skip to Section IV.

3. Water heater model number:

4. Water heater rebate amount:

7. Water heater gallon capacity:

5. Date water heater installed:

OR tankless/instantaneous water heater

$

III. Heat Pump Installation

13. Tons: 14. SEER/EER:

/ /

9. Heat pump model number:

10. Heat pump rebate amount:

$11. Date heat pump installed:

12. Heat pump manufacturer:

PG 1 OF 22009-3 ©Inside Information® Inc.

Yes No15. Is heat pump variable or 2 speed?Yes No16. Is there a water heater attached?

17. What type of back-up (supplemental) heating system do you have?

Heat pumpCentral air

Window unitOther

None18. What type was your previous air conditioning system?

19. Who installed your heat pump?

None, new construction/installationAir source heat pumpGround source heat pumpElectric baseboard/ceiling cableOther

Electric resistance heatNatural gas furnacePropane gas furnaceWood

20. This heat pump is replacing:

Existing gas furnaceNew gas furnaceExisting electric furnaceNew electric furnace

Electric strip heatWoodOtherNone

III. Heat Pump Installation (continued)

Safety Award Rebate & Consumer Database Survey

Lake Region Electric Cooperative

IV. ENERGY STAR® Appliance Installation

If you didn't also install other ENERGY STAR® appliances, skip toSection V.

For ENERGY STAR® window air conditioner:21. Window unit model number:

22. Window unit rebate amount: 23. Date window unit installed:

/ /24. Window unit manufacturer:

For ENERGY STAR® clothes washer:

$

25. Clothes washer model number:

26. Washer rebate amount:

$

27. Date washer installed:

/ /Form continues on back, please continue -->

Account Number

62628

(*Page Link, must match page 1)

Safety Award Rebate & Consumer Database Survey

Lake Region Electric Cooperative

IV. ENERGY STAR® Appliance Installation (continued)28. Clothes washer unit manufacturer:

29. Dishwaser model number:

30. Dishwasher rebate amount:

$

31. Dishwasher installed:

/ /32. Dishwasher manufacturer:

For ENERGY STAR® dishwasher:

NewspaperRadioTVCooperative newsletterBrochure/direct mailAppliance dealer

Builder/contractorCo-op employeeFriend/relativeCooperative websiteManufacturer websiteOther

NewspaperRadioTVCooperative newsletterBrochure/direct mailAppliance dealer

Builder/contractorCo-op employeeFriend/relativeCooperative websiteManufacturer websiteOther

Availability of rebateSafetyCleanliness (no vents/exhaust)Dissatisfaction with previous unit

Special co-op financingDissatisfaction with other fuelWarranty/service contractOther

36. How did you first learn about the cooperative rebate? (pick one)

33. When you made the decision to purchase this unit, what were the most important factors influencing your purchase? (all that apply)

V. Purchasing Decisions

35. Who made the decision to buy this unit?

34. How long did you research or browse before deciding to buy?

Home owner Builder Contractor Other

Less than 2 days2 days - 1 week

1 week - 1 month1 month - 6 months

More than 6 monthsI didn't decide

37. When making this purchase decision, what were your most important sources of product information? (all that apply)

PG 2 OF 22009-3 ©Inside Information® Inc.

VI. Your Heating & Cooling Systems38. What fuel does your water heater use?

Electricity Natural gas Propane Other

50. Age of the primary account holder:

51. How many people live in your home?1 2 3 4 5 6+

52. What is the occupation of the primary account holder?

53. What is the highest education level of the primary account holder?

Under 2525 - 34

35 - 4445 - 54

55 - 6465 - 74

75+

White collarBlue collar

Farmer/agricultureUnemployed/disabled

ProfessionalRetired

Less than high school diplomaHigh school graduate/GEDVocational/Trade training

Some collegeCollege graduateGraduate or professional school

VIII. Other Information

40. What is your home's main source of heat?

41. Approximately when was your heating system installed?

42. What type of air conditioning system do you have?Geothermal heat pumpAir source heat pump

Window unitEvaporative cooler

Central airNone

39. Approximately what year was your water heater installed?VI. Your Heating & Cooling Systems (continued)

1990 or before1991 - 1995

1996 - 20002001 - 2005

After 2005New with rebate

ElectricityNatural gas

Propane WoodOther (specify)

1985 or before1986 - 1990

1991 - 19951996 - 2000

2001 - 2005After 2005

New with rebate

VII. Your Home43. Do you own or rent your home? Own Rent44. How many square feet of living space do you have?

Less than 1,0001,000 - 1,499

1,500 - 1,9992,000 - 2,499

2,500 - 2,9993,000 or more

45. Approximately when was your home built?

46. Which best describes your account?Single family residenceMobile/modular homeApartment/condo/duplex

Vacation/seasonal homeFarmNon-residence

Before 19601960 - 19691970 - 1979

1980 - 19891990 - 19941995 - 1999

2000 - 20042005 and afterNew construction

47. Which of the following do you use in your home? (all that apply)

48. What type of Internet access do you have, if any?NoneDial-up

Cable broadbandDSL/T-1

Satellite Land-based wirelessOther

Satellite dishSecurity lightSecurity system

Standby generatorGenerlinkLife support

1 Personal computer2 or more computersSurge protection

49. E-mail:

Account Number

62628

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